Provider Demographics
NPI:1043405772
Name:WIERSIG CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:WIERSIG CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:D
Authorized Official - Last Name:WIERSIG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:405-737-5653
Mailing Address - Street 1:2013 S AIR DEPOT BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-5523
Mailing Address - Country:US
Mailing Address - Phone:405-737-5653
Mailing Address - Fax:405-733-5656
Practice Address - Street 1:2013 S AIR DEPOT BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-5523
Practice Address - Country:US
Practice Address - Phone:405-737-5653
Practice Address - Fax:405-733-5656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3048111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK443545904001OtherBLUE CROSS
OKT91026Medicare PIN